2.1 Definisi Attention Deficit Hyperactivity Disorder (ADHD) atau Hiperaktif.

ADHD adalah istilah popular, kependekan dari attention deficit hyperactivity disorder, (Attention = perhatian, Deficit = berkurang, Hiperactivity = hiperaktif dan Disorder = gangguan). Diartikan dalam Bahasa Indonesia, ADHD berarti gangguan pemusatan perhatian disertai hiperaktif. Attention Deficit Hyperactivity Disorder (ADHD) atau Hiperaktif adalah gangguan perkembangan dalam peningkatan aktifitas motorik anak-anak hingga menyebabkan aktifitas anak-anak yang tidak lazim dan cenderung berlebihan. ADHD sekitar tiga kali lebih sering terjadi pada anak laki-laki dibandingkan anak perempuan. Dr. Seto Mulyadi dalam bukunya Mengatasi Problem Anak Sehari-hari mengatakan pengertian istilah anak hiperaktif adalah suatu pola perilaku yang menetap pada seorang anak. Perilaku ini ditandai dengan sikap tidak mau diam, tidak bisa berkonsentrasi dan bertindak sekehendak hatinya atau impulsif. ADHD, juga dikenal sebagai gangguan perhatian defisit (ADD) atau gangguan hyperkinetic, telah ada lebih lama daripada kebanyakan orang sadari. Bahkan, kondisi yang muncul untuk menjadi serupa dengan ADHD digambarkan oleh Hippocrates, yang tinggal 460-370 SM. Nama Perhatian Defisit Disorder pertama kali diperkenalkan pada tahun 1980 di DSM-III, edisi ketiga dari "Diagnostik dan Statistik Manual of Mental Disorders", digunakan dalam psikiatri. Pada tahun 1994 definisi telah diubah untuk memasukkan tiga kelompok dalam ADHD: jenis dominan hiperaktif-impulsif, tipe didominasi inatentif, dan jenis gabungan. ADHD biasanya muncul pada masa kanak-kanak tetapi dapat didiagnosis pada orang dewasa.

2.2 Karakteristik Attention Deficit Hyperactivity Disorder (ADHD) atau Hiperaktif.

Sekarang ini, anak ADHD dibedakan ke dalam tiga tipe. Pertama, tipe ADHD gabungan. Kedua, tipe ADHD kurang memerhatikan. Ketiga, tipe ADHD hiperaktif impulsive. 1. Tipe ADHD gabungan Untuk mengetahui ADHD tipe ini, dapat didiagnosis/dideteksi oleh adanya paling sedikit 6 di antara 9 kriteria untuk perhatian, ditambah paling sedikit 6 di antara 9 kriteria untuk hiperaktivitas impulsifitas. Munculnya enam gejala tersebut berkali-kali sampai dengan tingkat yang signifikan disertai adanya beberapa bukti, antara lain sebagi berikut. a. b. c. d. 2. Gejala-gejala tersebut tampak sebelum anak mencapai usia 7 tahun. Gejala-gejala diwujudkan pada paling sedikit dua tempat yang berbeda. Gejala yang muncul menyebabkan hambatan yang signifikan dalam kemampuan akademik. Gangguan ini tidak dapat dijelaskan dengan lebih baik oleh kondisi psikologi atau psikiatri. Tipe ADHD kurang memerhatikan dan Tipe ADHD hiperaktif impulsif. Untuk mengetahui ADHD tipe ini, dapat didiagnosis/dideteksi oleh adanya paling sedikit 6 di antara 9 kriteria untuk perhatian dan mengakui bahwa individu-individu tertentu mengalami sikap kurang memerhatikan yang mendalam tanpa hiperaktifvitas/impulsifitas. Hal ini merupakan salah satu alasan mengapa dalam beberapa buku teks, kita menemukan ADHD ditulis dengan garis AD/HD. Hal ini membedakan, ahwa ADHD kurang memerhatikan dari jenis ketiga yang dikenal dengan tipe hiperaktif impulsif. 3. Tipe ADHD hiperaktif impulsive Tipe ketiga ini menuntut paling sedikit 6 diantara 9 gejala yang terdaftar pada bagian hiperaktif impulsifitas. Tipe ADHD kurang memerhatikan ini mengacu pada anak-anak yang mengalami kesulitan lebih besar dengan memori (ingatan) mereka dan kecepatan motor perceptual (persepsi gerak), cenderung untuk melamun, dan kerap kali menyendiri secara sosial.

2.2.1 Kriteria ADHD dari DSM IV (1994)

Berikut ini kriteria ADHD berdasarkan Diagnostic Statistical Manual. A.1 Kurang Perhatian a. Seringkali gagal memerhatikan baik-baik terhadap sesuatu yang detail b. Seringkali mengalami kesulitan dalam memusatkan perhatian terhadap tugas-tugas atau kegiatan bermain. c. Seringkali tidak mendengarkan jika diajak bicara langsung d. Seringkali tidak mengikuti baik-baik intruksi dan gagal dalam menyelesaikan pekerjaan sekolah, pekerjaan atau tugas di tempat kerja. e. Seringkali mengalami kesulitan dalam menjalankan tugas dan kegiatan. f. Seringkali kehilangan barang/benda yang penting untuk tugas-tugas dan kegiatan. g. Seringkali mengihndari, tidak menyukai atau enggan untuk melaksanakan tugas-tugas yang membutuhkan usaha mental yang didukung. h. Seringkali bingung/terganggu oleh rangsangan dari luar. i. Seringkali lekas lupa dalam menyelesaikan kegiatan sehari-hari. A.2 Hiperaktifitas Impulsifitas. Paling sedikit enam atau lebih dari gejala-gejala hiperaktivitas impulsifitas berkutnya bertahan selama paling sedikit 6 bulan sampai dengan tingkatan yang maladaptif dan tidak dengan tingkat perkembangan. a. b. c. d. e. f. a. b. c. Hiperaktivitas. Seringkali gelisah dengan tangan atau kaki mereka dan sering mengggeliat di kursi. Sering meninggalkan tempat duduk di dalam kelas Sering berlarian atau naik-naik secara berlebihan dalam situasi di mana hal ini tidak tepat. Sering mengalami kesulitan dalam bermain atau terlibat dalam kegiatan senggang secara tenang. Sering bergerak atau bertindak seolah-olah dikendalikan oleh motor. Sering berbicara berlebihan. Impulsifitas Mereka sering memberi jawaban sebelum pertanyaan selesai. Mereka sering mengalami kesulitan menanti giliran. Mereka sering mengintrupsi orang lain.

B. Beberapa gejala hiperaktivitas impulsifitas atau kurang perhatian yang menyebabkan gangguan muncul sebelum anak berusia 7 tahun. C. Ada sesuatu di dua atau lebih setting/situasi. D. Harus ada gangguan yang secara klinis, signifikan di dalam fungsi sosial, akademik, atau pekerjaan. E. Gejala-gejala tidak terjadi selamanya berlaku PDD,skizofrenia, atau gangguan psikotik lainnya dan tidak dijelaskan dengan lenbih baik oleh gangguan mental lainnya.

2.3 Faktor Penyebab Attention Deficit Hyperactivity Disorder (ADHD) atau Hiperaktif. ADHD bukan disebabkan oleh parenting yang buruk, terlalu banyak asupan gula atau MSG, ataupun gara-gara vaksin. ADHD itu berawal dari masalah biologis yang belum seratus persen dapat dipahami. Dalam hal ini, tidak ada penyeba tunggal untuk ADHD. Para ahli telah meneliti beberapa kemungkinan dari faktor genetik dan lingkungan. Berikut ini komentar orang tua mengenai ADHD, Gangguan ADHD dapat merusak hidup anak, menghabiskan banyak energy, menimbulkan rasa sakit secara emosional, menurunkan harga diri dan secara serius merusak hubungan kekerabatan atau pertemanan. 2

Beberapa hal yang dapat menyebabkan perilaku hiperaktif ialah : a. Kondisi saat hamil & persalinan. Misalnya keracunan pada akhir kehamilan (ditandai dengan tingginya tekanan darah, pembengkakan kaki & ekskresi protein melalui urine), cedera pada otak akibat komplikasi persalinan. b. c. Cedera otak sesudah lahir,yang disebabkan oleh benturan kuat pada kepala anak. Tingkat keracunan timbal yang parah dapat mengakibatkan kerusakan otak. Hal ini ditandai dengan kesulitan konsentrasi, belajar dan perilaku hiperaktif. Polusi timbal berasal dari industri peleburan baterai, mobil bekas, asap kendaraan atau cat rumah yang tua. Obat untuk mengeluarkan timbal dari dalam tubuh hanya diberikan dibawah pengawasan dokter bagi anak kadar timbalnya sudah sangat tinggi, karena obat tersebut mempunyai efek samping. d. Lemah pendengaran, yang disebabkan infeksi telinga sehingga anak tidak dapat mereproduksi bunyi yang didengarnya. Akibatnya, tingkah laku menjadi tidak terkendali & perkembangan bahasanya yang lamban. Segeralah hubungi dokter THT jika anak menunjukkan ciri berikut: perkembangan bahasa yang lambat, lebih banyak memperhatikan mimik lawan bicara & lebih banyak berreaksi terhadap perubahan mimik & isyarat. e. Faktor psikis, yang lebih banyak dipengaruhi oleh hubungan anak dengan dunia luar. Meskipun jarang, hubungan dengan anggota keluarga dapat pula menjadi penyebab hiperaktivitas. Contoh kasus, orang tua yang bersikap sangat tegas menyuruh anak berdiri 15 menit di pojok ruangan untuk mengatasi ketidakdisiplinannya. Tapi setelah 15 menit berlalu, maka anak malah mempunyai energi berlebih yang siap meledak dengan akibat lebih negatif dibanding kesalahan sebelumnya. Faktor-faktor penyebab hiperaktif pada anak 1. Faktor neurologik Insiden hiperaktif yang lebih tinggi didapatkan pada bayi yang lahir dengan masalah-masalah prenatal seperti lamanya proses persalinan, distres fetal, persalinan dengan cara ekstraksi forcep, toksimia gravidarum atau eklamsia dibandingkan dengan kehamilan dan persalinan normal. Di samping itu faktor-faktor seperti bayi yang lahir dengan berat badan rendah, ibu yang terlalu muda, ibu yang merokok dan minum alkohol juga meninggikan insiden hiperaktif Terjadinya perkembangan otak yang lambat. Faktor etiologi dalam bidang neuoralogi yang sampai kini banyak dianut adalah terjadinya disfungsi pada salah satu neurotransmiter di otak yang bernama dopamin. Dopamin merupakan zat aktif yang berguna untuk memelihara proses konsentrasi. 2. Faktor toksik Beberapa zat makanan seperti salisilat dan bahan-bahan pengawet memilikipotensi untuk membentuk perilaku hiperaktif pada anak. Di samping itu, kadar timah (lead) dalam serum darah anak yang meningkat, ibu yang merokok dan mengkonsumsi alkohol, terkena sinar X pada saat hamil juga dapat melahirkan calon anak hiperaktif.

3.

Faktor genetik Didapatkan korelasi yang tinggi dari hiperaktif yang terjadi pada keluarga dengan anak hiperaktif. Kurang lebih

sekitar 25-35% dari orang tua dan saudara yang masa kecilnya hiperaktif akan menurun pada anak. Hal ini juga terlihat pada anak kembar. 4. Faktor Kultural dan psikososial a. Pemanjaan. Pemanjaan dapat juga disamakan dengan memperlakukan anak terlalu manis, membujuk-bujuk makan, membiarkan saja, dan sebagainya. Anak yang terlalu dimanja itu sering memilih caranya sendiri agar terpenuhi kebutuhannya. b. Kurang disiplin dan pengawasan.

Anak yang kurang disiplin atau pengawasan akan berbuat sesuka hatinya, sebab perilakunya kurang dibatasi. Jika anak dibiarkan begitu saja untuk berbuat sesuka hatinya dalam rumah, maka anak tersebut akan berbuat sesuka hatinya ditempat lain termasuk di sekolah dan orang lain juga akan sulit untuk mengendalikannya. c. Orientasi kesenangan. Anak yang memiliki kepribadian yang berorientasi kesenangan umumnya akan memiliki ciri-ciri hiperaktif secara sosio-psikologis dan harus dididik agak berbeda agar mau mendengarkan dan menyesuaikan diri. Anak yang mempunyai orientasi kesenangan ingin memuaskan kebutuhan atau keinginan sendiri. 2.4 Pelayanan Pembelajaran Attention Deficit Hyperactivity Disorder (ADHD) atau Hiperaktif. Menurut mengarahkan sebagaimana Moeslichatoen anak. Adapun Moeslichatoen ada beberapa menjelaskan metode metode dalam yang tersebut cocok akan untuk dijelaskan Metode membimbing di bawah pengajaran dan ini di

keseluruhan

bukunya

Taman Kanak-Kanak.

1.

Metode Bercerita Metode prinsip-prinsip anak-anak bagi anak cerita rohani. usia secara haruslah Dunia dapat 3-5 lisan. juga digunakan cerita oleh terjadi Allah untuk mengajarkan yang satu usia dan maka lucu, menarik. pemberian ini dalam tidak kepada manusia cerita tentang bagi belajar tentang konsep haruslah Karena dan

Dalam tahun

peristiwa salah bagi anak

Metode

merupakan bercerita mengundang

pengalaman mengajarkan lepas dari bercerita

Metode

kebenaran bercerita. diusahakan dunia

menarik, kehidupan

perhatian sukacita,

anak

itu

penuh

kegiatan dan

memberikan anak itu

perasaan, dapat

gembira, dengan

mengasyikkan. keluarga, sekolah

kehidupan

berkaitan

lingkungan

diluar lingkungannya. Moeslichatoen dipergunakan menggunakan antara illustrasi mengatakan lain guru dari bahwa atau buku ada orang gambar, beberapa tua macam dapat teknik bercerita langsung flanel, yang dari dapat buku,

membaca papan

menggunakan

menggunakan

boneka, bermain peran dalam suatu cerita. 2. Metode tanya-jawab. Dengan komunikasi. yang sesuatu yang bertanya maka sesuai yang memiliki kepada anak Itu adanya juga dengan dapat perilaku anak tersebut metode tanya-jawab persiapan ini akan yang membuat baik kala bingung tidak baru agar ada antara dapat anak anak dan guru ada

diperlukan

memberikan hiperaktif

jawaban menanyakan

kebenarannya. membuat yang mengenai akan guru

Kadang menjadi itu yang

untuk bisa saja

menjawabnya. guru

Saat

anak langsung

berlebihan cerita memberikan

diam,

dapat Dengan yang

diceritakan. kepada guru

cara

ini

perhatiannya

bertanya.

Walaupun rentang konsentrasi anak seperti itu sangat singkat. 3. Metode pekerjaan tangan. Guru/pembimbing yang dari anak anak memiliki lilin, sesuai yang perlaku anak dapat memberikan atau yang diajarkan dapat yang metode tidak pekerjaan mau diam, Hal Dengan diatas, tangan seperti ini kepada anak bentuk oleh maka tidak

berlebihan kanji yang tadi

membuat harus metode anak dibuat ini itu

melukis dengan tidak

dengan apa

berwarna oleh diberikan

warni. guru.

tersebut adanya

mau

diam

kegiatan

sehingga

lagi mengganggu teman yang lainnya saat berada di kelas. 4. Metode pemberian tugas. 4

Metode kepada temannya yang anak mulai

pemberian yang tidak

tugas mau

merupakan diam,

tugas supaya

atau

pekerjaan si

yang anak

sengaja untuk

diberikan mengganggu batas untuk diberikan harus dan bagi minat

kesempatan juga anak harus yang

berkurang.

Pemberian nyata. karena

tugas

itu

jelas

dan

penentuan hambatan yang yang waktu bermakna

tepat

diberikan kemajuan untuk anak suatu tugas akan

secara belajar

Banyak tidak Kejelasan

mengalami batas batas tugas tugas

memperoleh oleh guru

menentunya penentuan anak

diselesaikan. memperkecil yang anak

diselesaikan tenaga anak. anak tugas tepat sehingga pemberian untuk

kemungkinan tidak seperti membuahkan ini juga kreatif. itu

membuang-buang dan dapat itu tidak

kegiatan kepada

hasil harus Anak

Pemberian untuk bila dan

membangkitkan tidak akan

mengembangkan yang diberikan

tugas oleh

itu guru

secara baginya

melakukan secara benar, Bila dengan

tidak

menarik. cara pada bervariasi,

Pemberian belajar dirinya dan

tugas yang sendiri.

profesional keinginan tugas

akan anak

dapat untuk

meningkatkan melakukannya bahan

bagaimana timbul yang

itu

menggunakan

sesuai

kebutuhan dan minat anak, maka akan memberikan arti yang besar bagi anak tersebut. 5. Metode bermain. Metode bermain juga sangat baik diberikan kepada anak tersebut karena anak akan belajar mengendalikan diri sendiri, memahami dunianya. Dengan menggunakan metode bermain kepada anak seperti ini diperlukan guru-guru yang harus menemaninya. Melalui kegiatan bermain anak dapat mengembangkan

kreativitasnya, yaitu melakukan kegiatan yang dapat menyalurkan bakat si anak. Bagi Karena baik anak seperti itu dirinya. cara ini, metode dengan kegiatan dapat ini dapat diberikan melakukan ini dan anak akan merasa sangat senang. cukup kasar. seperti

anak bagi

dapat Melalui dan

bebas

kegiatannya anak dapat

yang

dirasakan otot

bermain

menggunakan kegiatan

Bermacam

teknik

dipergunakan

dalam

tersebut

merayap, berlari, merangkak, berjalan, melompoat, menendang, melempar Guru/pembimbing tidak cepat bosan yang anak dengan dapat cara melakukan yang aturan metode oleh Anak bermain guru. seperti ini Seperti ini sehingga mengajak akan anak anak tersebut untuk untuk

diberikan main.

bernyanyi

menggunakan

tertarik

melakukannya. Kegiatan kegiatan menggunakan dapat seperti bermain dapat anak tenaga rasa caranya ingin memasak, membantu memperoleh dan penyaluran kelebihan tenaga. antara memerlukan Setelah kegiatan ketenangan. metode tidak bermain diberi air, melakukan dengan Anak ini dan

bermain kekuatan

keseimbangan yang

kegiatan dengan

menyalurkan bagaimana

tahunya mengapa

menggunakan layu bila

pohon

sebagainya. Kegiatan kegiatan kertas menggambar Anak Cara dapat dalam seperti juga diberikan kepada dapat salah anak hiperaktif termasuk warna yang didalam dan dapat

bermain. gambar.

menggambar ini merupakan

menggunakan satu

pensil kegiatan

menyalurkan tenaga pada dirinya.

2.5 Penanganan dan Alternatif Penyembuhan Attention Deficit Hyperactivity Disorder (ADHD) atau Hiperaktif. Melihat penyebab ADHD yang belum pasti terungkap dan adanya beberapa teori penyebabnya, maka tentunya banyak sekali terapi atau cara dalam penanganannya sesuai dengan landasan teori penyebabnya. Ada satu hal yang perlu diketahui, bahwa tak ada penyembuhan ADH. Beberapa terapi untuk anak hiperaktif : 5

1. Terapi Farmakologi Adalah penanganan dengan menggunakan obat- obatan. Terapi ini hendaknya hanya sebagai penunjang dan sebagai kontrol terhadap kemungkinan timbulnya impuls impils hiperaktif yang tidak terkendali. Rencana pengobatan harus dibuat secara individual, tergantung gejala dan efeknya terhadap kehidupan sehari-hari. Penelitian jangka panjang menunjukkan bahwa kombinasi obat dan terapi lain memberi hasil paling baik. Pengobatan diberikan bila gejala impulsivitas, agresivitas, dan hiperaktivitas cukup berat sehingga menyebabkan gangguan di sekolah, di rumah, atau hubungan dengan teman. Pengobatan bertujuan menghilangkan gejala dan sangat memudahkan terapi psikologis. Lamanya pengobatan tergantung ada atau tidaknya gejala yang ingin dihilangkan. Saat ini tersedia beragam tipe pengobatan yang dapat digunakan dalam menangani ADHD. a. Stimulans. Merupakan jenis obat yang paling sering digunakan dan sudah lebih 50 tahun dipakai dalam menangani ADHD. Dosis yang diberikan pun bervariasi, ada yang setiap 4 jam adapula yang lebih dari 12 jam . Sementara efek samping yang mungkin timbul, antara lain, nafsu makan menurun, sakit perut, snewen dan insomnia. b.NonStimulans Mulai dianjurkan untuk menangani ADHD pada tahun 2003. Obat ini diketahui mempunyai efek samping yang lebih sedikit dibandingkan tipe stimulant, dan masa paruh pakainya lebih dari 24 jam. c. Antidepressants. Terkadang dijadikan salah satu opsi dalam menangani ADHD, tetapi pada tahun 2004 Food and Drug Administration (FDA) mengeluarkan peringtan bahwa obat ini dapat memicu gejala aneh yang meningkatkan risiko terjadinya bunuh diri di antara anak dan remaja yang menggunakannya. Jika anak kita diberi resep antidepressant, maka penting sekali untuk mendiskusikan risiko-risiko diatas dengan dokter. Sebagai catatan, efek yang diberikan dari obat-obatan di atas akan berbeda-beda pada setiap anak. Efek samping seperti hilangnya selera makan, kesulitan tidur, atau mengantuk didalam kelas kerap kali dapat dikendalikan melalui penyesuaian dosis obat-obatan. Dengan demikian, untuk menemukan dosis yang paling tepat, dokter akan mencoba beragam jenis obat dan dosisnya khusunya, bila menangani anak ADHD yang disertai dengan kelainan lainnya. 2. Terapi Bermain Terapi bermain sangat penting untuk mengembangkan keterampilan, kemampuan gerak , minat dan terbiasa dengan suasana kompetitif dan kooperatif dalam melakukan kegiatan kelompok. Bermain juga dapat dipakai untuk sarana persiapan beraktivitas dan bekerja saat dewasa. 3. Terapi Perilaku Terapi psikososial/perilaku, seperti pelatihan kemampuan sosial, dapat dianjurkan sebagai terapi awal bila gejala ADHD cukup ringan, diagnosis ADHD belum pasti, atau keluarga memilih terapi ini. Namun, untuk jangka panjangnya, terapi perilaku saja tidak cukup dalam menangani ADHD. Berikut beberapa contoh strategi-strategi perilaku yang dapat membantu anak dengan ADHD. a. Menjadwal Rutinitas Harian. Cobalah untuk megikuti jadwal kegiatan yang sama setiap hari dari bangun tidur sampai tidur lagi. Taruh jadwal tersebut di tempat yang dapat dilihat dengan mudah sehingga anak pun tahu. b. Keteraturan dan kerapian. Taruh tas sekolah, pakaian dan mainan di tempat yang telah ditentukan. Dengan demikian, risiko kehilangan bendabenda milik pribadi anak menjadi kecil.

c.

Mengurangi Distraksi. Matikan TV, radio dan game komputer khususnya pada saat anak sedang belajar atau mengerjakan PR. 6

d. Batasi pilihan-pilihan. Jika menawarkan sesuatu, batasi pilihan yang ditawarkan menjadi DUA pilihan saja. Misal, Dede mau es krim atau es cendol. Kebiasaan di atas dapat mencegah anak dari kebingungan dan overstimulasi. e. Mengubah Gaya Interaksi dengan Anak. Anak ADHD lebih mudah memahami perintah dan petunjuk yang ringkas, jelas, dan singkat daripada perintah dan petunjuk yang banyak penjelasan dan bertele-tele. f. Buat daftar Goals dan Rewards. Buat daftar perilaku baik yang berhasil ditampilkan anak sesuai dengan permintaan kita, kemudian beri imbalan yang pantas kepadanya. Tetapi, pastikan goal yang kita inginkan itu realistis karena tidak ada yang namanya sukses dalam semalam! g. Menerapkan Disiplin yang efektif. Daripada memarahi atau memukul, lebih baik gunakan mettode timeouts atau mengurangi fasilitas-fasilitas yang biasa kita berikan pada anak sebagai konsekuensi untuk perilaku buruk yang ditampilkan anak. Untuk anak yang masih kecil, cukup kita alihkan perhatian atau tunggu saja, dia pun akan normal kembali.

h. Bantu Anak Menemukan Bakatnya. Semua anak perlu mendapat perasaan sukses agar dapat merasa baik terhadap diri mereka sendiri. Temukan dan beri pujian pada setiap pencapaian yang berhasil ditampilkan anak, apakah itu di bidang olahraga, musik, menggambar, mengarang dan lain-lain. Tindakan seperti ini dapat memacu perkembangan keahlian sosial anak serta dapat menumbuhkan rasa percaya diri anak.

Signs and symptoms

Children with ADHD tend to get distracted from schoolwork rather easily, and they often behave disruptively.[21] Inattention, hyperactivity, disruptive behavior and impulsivity are common in ADHD.[22][21] Academic difficulties are also frequent.[21] The symptoms are especially difficult to define because it is hard to draw a line at where normal levels of inattention, hyperactivity, and impulsivity end and clinically significant levels requiring intervention begin.[23] To be diagnosed with ADHD, symptoms must be observed in two different settings for six months or more and to a degree that is greater than other children of the same age.[24] The symptom categories yield three potential classifications of ADHDpredominantly inattentive type, predominantly hyperactive-impulsive type, or combined type if criteria for both subtypes are met:[25] Predominantly inattentive type symptoms as listed by the U.S. National Institute of Mental Health may include:[26]

Be easily distracted, miss details, forget things, and frequently switch from one activity to another Have difficulty maintaining focus on one task Become bored with a task after only a few minutes, unless doing something enjoyable

Have difficulty focusing attention on organizing and completing a task or learning something new or trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities

Not seem to listen when spoken to Daydream, become easily confused, and move slowly Have difficulty processing information as quickly and accurately as others Struggle to follow instructions.

Predominantly hyperactive-impulsive type symptoms may include:[26]

Fidget and squirm in their seats Talk nonstop Dash around, touching or playing with anything and everything in sight Have trouble sitting still during dinner, school, and story time Be constantly in motion Have difficulty doing quiet tasks or activities

and also these manifestations primarily of impulsivity:[26]

Be very impatient Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences Have difficulty waiting for things they want or waiting their turns in games

Most people exhibit some of these behaviors, but not to the degree where such behaviors significantly interfere with a person's work, relationships, or studiesand in the absence of significant interference or impairment, a diagnosis of ADHD is normally not appropriate. The core impairments are consistent even in different cultural contexts. [27] Some children, adolescents, and adults with ADHD have an increased risk of experiencing difficulties with social skills, such as social interaction and forming and maintaining friendships. About half of children and adolescents with ADHD experience rejection by their peers compared to 10-15 percent of non-ADHD children and adolescents. Training in social skills, behavioural modification and medication may have some limited beneficial effects. The most important factor in reducing emergence of later psychopathology, such as major depression, criminality, school failure, andsubstance use disorders is formation of friendships with people who are not involved in delinquent activities.[28] Adolescents with ADHD are more likely to have difficulty making and keeping friends due to impairments in processing verbal and nonverbal language.[29] Handwriting difficulties seem to be common in children with ADHD.[30] Delays in speech and language as well as motor development occur more commonly in the ADHD population.[30][31][32] A 2009 study found that children with ADHD move around a lot because it helps them stay alert enough to complete challenging tasks.[33][34] Associated disorders Inattention and hyperactive behavior are not necessarily the only problems in children with ADHD. ADHD exists alone in only about 1/3 of the children diagnosed with it. The combination of ADHD with other conditions can greatly complicate diagnosis and treatment. Many co-existing conditions require other courses of treatment and should be diagnosed separately instead of being grouped in the ADHD diagnosis. Some of the associated conditions are:

Oppositional defiant disorder and conduct disorder, which occur with ADHD at a rate of 50 percent and 20 percent respectively,[35] are characterized by antisocial behaviors such as stubbornness, aggression, frequent temper tantrums, 8

deceitfulness, lying, or stealing,[36] inevitably linking these comorbid disorders with antisocial personality disorder (ASPD); about half of those with hyperactivity and ODD or CD develop ASPD in adulthood.[37] However, modern brain imaging technology indicates that conduct disorder and ADHD are two distinct disorders. [38]

Borderline personality disorder, which was according to a study on 120 female psychiatric patients diagnosed and treated for BPD associated with ADHD in 70 percent of those cases.[39]

Primary disorder of vigilance, which is characterized by poor attention and concentration, as well as difficulties staying awake. These children tend to fidget, yawn and stretch and appear to be hyperactive in order to remain alert and active.[36]

Mood disorders (especially Bipolar disorder and Major depressive disorder). Boys diagnosed with the combined ADHD subtype have been shown to be more likely to suffer from a mood disorder.[40]

Bipolar disorder. Adults with ADHD sometimes have co-morbid bipolar disorder, which requires careful assessment in order to accurately diagnose and treat both conditions.[41] Anxiety disorders, have been found to occur more commonly in the ADHD population.[40] Obsessive-compulsive disorder. OCD can co-occur with ADHD and shares many of its characteristics.[36] Substance use disorders. Adolescents and adults with ADHD are at a significantly increased risk of developing a substance abuse problem which can interfere with the evaluation and treatment of ADHD. The most commonly misused substances by the ADHD population are alcohol and cannabis; serious substance misuse problems should be treated first due to the serious risks and impairments that occur,[14]:p.38[42] with long-term alcohol misuse and longterm cannabis misuse and other drug misuse.

There is a strong association between persistent bed wetting and ADHD[43] as well as dyspraxia with up to 50 percent of dyspraxics having ADHD.[44] Multiple research studies have also found a significant association between ADHD and language delay.[45] Anxiety and depression are some of the disorders that can accompany ADHD. Academic studies, and research in private practice suggest that depression in ADHD appears to be increasingly prevalent in children as they get older, with a higher rate of increase in girls than in boys, and to vary in prevalence with the subtype of ADHD. Where a mood disorder complicates ADHD, it would be prudent to treat the mood disorder first, but parents of children with ADHD often wish to have the ADHD treated first, because the response to treatment is quicker.[46] In children who have a high IQ There has been some controversy as to whether ADHD children with a high IQ have significant impairments. Research has shown that high IQ children with ADHD are more likely to repeat grades and have more social and functional impairments; more than half require additional academic support compared to children without ADHD. Additionally, more than half of high IQ ADHD people experience major depressive disorder or oppositional defiant disorder at some point in their lives. Generalised anxiety disorder, separation anxiety disorder and social phobia is also more common in high IQ ADHD individuals. There is some evidence that high IQ ADHD individuals are not at an increased risk of substance abuse and conduct disorder compared to low and average IQ ADHD young people. High IQ children and adolescents with ADHD can have their high intelligence level missed when standard testing is performed; high IQ ADHD people tend to require more comprehensive testing to detect their true intelligence level.[47] High IQ ADHD children have a unique neuropsychological profile which typically shows a gap of 20 points or more between the verbal IQ and the performance IQ when tested on the Wechsler Intelligence Scale for Children; high IQ children without ADHD do not usually present with this sizable gap.[48] Cause The specific causes of ADHD are not known.[49] There are, however, a number of factors that may contribute to, or exacerbate ADHD. They include genetics, diet and the social and physical environments. 9

Genetics Twin studies indicate that the disorder is highly heritable and that genetics are a factor in about 75 percent of all cases.[14] Hyperactivity also seems to be primarily a genetic condition; however, other causes have been identified.[50] A large majority of ADHD cases may arise from a combination of various genes, many of which affect dopamine transporters. Candidate genes include DAT1, DRD4, DRD5, 5HTT, HTR1B, andSNAP25. There is also strong heterogeneity for the associations between ADHD and DAT1, DRD4, DRD5, dopamine beta hydroxylase, ADRA2A, 5HTT, TPH2, MAOA, and SNAP25.[51] A common variant of a gene called LPHN3 is estimated to be responsible for about 9% of the incidence of ADHD, and ADHD cases where this gene is present are particularly responsive to stimulant medication.[52] Executive functions Cognitive processes that regulate, control, and manage other cognitive processes are termed "executive functions" (EF).[53] Examples of such regulated processes are planning, working memory,attention, inhibition, mental flexibility, and initiation and monitoring of actions.[54] One of the most noticeable neuropsychologic theories of ADHD suggests that its symptoms arise from a primary deficit in executive functions (EF).[55] A 2005 review found that groups with ADHD showed significant impairment on all EF tasks. The strongest effects were on measures of response inhibition, vigilance, working memory, and planning. However, the effect sizes were moderate and there were also individual differences.[55] Not all individuals with ADHD show deficits in executive functioning;[56] the criteria for an executive function deficit are met in 3050% of children and adolescents with ADHD.[57] Furthermore, deficits in EF are not unique to ADHD.[56] For example, deficits in executive function are seen in individuals with oppositional defiant disorder and conduct disorder.[56] One study found that 80% of individuals with ADHD was impaired in at least one EF task, compared to 50% for individuals without ADHD.[58] The 2005 review concluded that deficits in certain executive functions play an important role in ADHD; however, "EF weaknesses are neither necessary nor sufficient to cause all cases of ADHD". [55] Evolution See also: Hunter vs. farmer hypothesis At more than 1 percent of the population, researchers have proposed that the high prevalence of ADHD may be due to natural selection having favoured ADHD, possibly because the individual traits may be beneficial on their own, and only become dysfunctional when these traits combine to form ADHD.[59] The high prevalence of ADHD may in part be because women in general are more attracted to males who are risk takers, thereby promoting ADHD in the gene pool.[60] Further evidence that hyperactivity might be evolutionarily beneficial was put forth in a 2006 study finding that it may carry specific benefits for certain forms of society. In these societies, those with ADHD are hypothesized to have been more proficient in tasks involving risk, competition, and/or unpredictable behavior (i.e. exploring new areas, finding new food sources, etc.), where these societies may have benefited from confining impulsive or unpredictable behavior to a small subgroup. In these situations, ADHD would have been beneficial to society as a whole even while severely detrimental to the individual.[60] More recent research suggests that because ADHD is more common in mothers who are anxious or stressed that ADHD is a mechanism of priming the child with the necessary traits for a stressful or dangerous environment, such as increased impulsivity and explorative behaviour etc.[61] A genetic variant associated with ADHD (DRD4 48bp VNTR 7R allele) has been found to be at higher frequency in more nomadic populations and those with more of a history of migration.[62] Consistent with this, another group of researchers observed that the health status of nomadic Ariaal men was higher if they had the ADHD associated genetic variant (7R alleles). However in recently sedentary (non-nomadic) Ariaal those with 7R alleles seemed to have slightly worse health.[63] Environmental 10

ADHD is predominantly a genetic disorder with environmental factors contributing a small role to the etiology of ADHD. Twin studies have shown that ADHD is largely genetic with 76 percent of the phenotypic variance being explained by inherited genetic factors.[64][65] Alcohol intake during pregnancy can cause the child to have a fetal alcohol spectrum disorder which can include symptoms similar to ADHD.[66] Exposure to tobacco smoke during pregnancy impairs normal development of the feotus including the central nervous system and can increase the risk of the child being diagnosed with ADHD.[67] Many children exposed to tobacco do not develop ADHD or else only have mild symptoms which do not reach the threshold of a diagnosis of ADHD. A combination of a genetic vulnerability to developing ADHD as well as the toxic developmental effects of tobacco on the foetus explain why some children exposed to tobacco smoke in utero develop ADHD and others don't.[68] Children exposed to lead, even relatively low levels of lead develop neurocognitive deficits which resemble ADHD and these children can fulfill the diagnostic criteria for ADHD. There is also some evidence that exposure to polychlorinated biphenyls during childhood causes developmental damage and can cause ADHD type symptoms which are the diagnosed as ADHD.[69] Exposure to the organophosphate insecticides chlorpyrifos and dialkyl phosphate is associated with an increased risk of ADHD. However, the evidence is not definitive as 5 of 17 studies failed to find an association.[70] Very low birth weight, premature birth and exceptional early adversity increase the risk of the child having ADHD.[71] At least 30 percent of children who experience a paediatric traumatic brain injury develop ADHD.[72] Infections during pregnancy, at birth, and in early childhood are linked to an increased risk of developing ADHD. These include various viruses (measles, varicella, rubella,enterovirus 71) and streptococcal bacterial infection.[73] Diet Main article: Diet and attention deficit hyperactivity disorder Concerns were first raised by Benjamin Feingold, a paediatric allergist that food colourings and additives may affect children's behaviour in 1973. There is evidence suggesting that some food colourings may make some children hyperactive. However, the evidence for a link between food colourings and hyperactive behaviour remains uncertain. The FDA interpreted the evidence as being inconclusive as to whether food colours caused hyperactivity or not. The FDA review of food colours has been criticised for only doing a very narrow investigation into food colourings and their possible association with causing hyperactivity instead of investigating their possible effect on neurobehaviour in general.[74] It is possible that certain food colourings act as a trigger for ADHD symptoms in subgroup of children who have a genetic vulnerability. The U.K, followed by the European Union took regulatory action on food colourings due to concerns about their possible adverse effects in children.[75] According to the Food Standards Agency, the food regulatory agency in the UK, food manufacturers were encouraged to voluntarily phase out the use of most artificial food colors by the end of 2009. Sunset yellow FCF (E110), quinoline yellow (E104), carmoisine (E122), allura red (E129), tartrazine (E102) and ponceau 4R (E124) are collectively called the "Southampton six". Following the FSAs actions, the European Commission ruled that any food products containing the contentious colourings must display warning labels on their packaging by 2010.[76] Social The World Health Organization states that the diagnosis of ADHD can represent family dysfunction or inadequacies in the educational system rather than individual psychopathology.[77] Other researchers believe that relationships with caregivers have a profound effect on attentional and self-regulatory abilities. A study of foster children found that a high number of them had symptoms closely resembling ADHD.[78] Researchers have found behavior typical of ADHD in children who have suffered violence and emotional abuse.[14][79] Individuals with posttraumatic stress syndrome(PTSD) show deficits in executive functions and in attention, and children with PTSD can be misdiagnosed with ADHD.[80] Social construct theory of ADHD 11

Main article: Social construct theory of ADHD Social construction theory states that it is societies that determine where the line between normal and abnormal behavior is drawn. Thus society members including physicians, parents, teachers, and others are the ones who determine which diagnostic criteria are applied and, thus, determine the number of people affected.[81] This is exemplified in the fact that the DSM IV arrives at levels of ADHD three to four times higher than those obtained with use of the ICD 10. [11] Thomas Szasz, a proponent of this theory, has argued that ADHD was "invented and not discovered."[82][83] Pathophysiology The pathophysiology of ADHD is unclear and there are a number of competing theories.[84] Research on children with ADHD has shown a general reduction of brain volume, but with a proportionally greater reduction in the volume of the left-sided prefrontal cortex. These findings suggest that the core ADHD features of inattention, hyperactivity, and impulsivity may reflect frontal lobe dysfunction, but other brain regions in particular the cerebellum have also been implicated.[85] Neuroimaging studies in ADHD have not always given consistent results and as of 2008 are used only for research and not diagnostic purposes.[86] A 2005 review of published studies involving neuroimaging, neuropsychological genetics, and neurochemistry found converging lines of evidence to suggest that four connected frontostriatal regions play a role in the pathophysiology of ADHD: The lateral prefrontal cortex, dorsalanterior cingulate cortex, caudate, and putamen.[87] It should be noted that stimulant medication itself may affect growth factors of the central nervous system.[88] The same laboratory had previously found involvement of the "7-repeat" variant of the dopamine D4 receptor gene, which accounts for about 30 percent of the genetic risk for ADHD, in unusual thinness of the cortex of the right side of the brain; however, in contrast to other variants of the gene found in ADHD patients, the region normalized in thickness during the teen years in these children, coinciding with clinical improvement.[89] Previously it was thought that the elevated number of dopamine transporters seen in ADHD patients was part of the pathophysiology of ADHD but it now appears that the reason for elevated striatal dopamine transporter density in ADHD individuals is due to neuroadaptations occurring due to the continuous exposure to stimulants such as methylphenidate or dexamphetamine as the body tries to counter-act the effects of the stimulants by developing a tolerance to the stimulant medications.[90] One interpretation of dopamine pathway tracers is that the biochemical "reward" mechanism works for those with ADHD only when the task performed is inherently motivating; low levels of dopamine raise the threshold at which someone can maintain focus on a task that is otherwise boring.[91] There is evidence that people with ADHD have a low arousal threshold and compensate for this with increased stimuli, which in turn results in disruption of attentional capacity and an increase in hyperactive behaviour. The reason for this is due to abnormalities in how the dopamine system in central nervous system responds to stimuli.[92] Critics, such as Jonathan Leo and David Cohen, who reject the characterization of ADHD as a disorder, contend that the controls for stimulant medication usage were inadequate in some lobar volumetric studies, which makes it impossible to determine whether ADHD itself or psychotropic medication used to treat ADHD is responsible for the decreased thickness observed[93] in certain brain regions. While the main study in question used age-matched controls, it did not provide information on height and weight of the subjects. These variables it has been argued could account for the regional brain size differences rather than ADHD itself.[94][95] They believe many neuroimaging studies are oversimplified in both popular and scientific discourse and given undue weight despite deficiencies in experimental methodology.[94][96] Diagnosis ADHD is diagnosed via a psychiatric assessment; to rule out other potential causes or comorbidities, physical examination, radiological imaging, and laboratory tests may be used.[97] 12

In North America, the DSM-IV criteria are often the basis for a diagnosis, while European countries usually use the ICD10. If the DSM-IV criteria are used, rather than the ICD-10, a diagnosis of ADHD is 34 times more likely.[11] Factors other than those within the DSM or ICD however have been found to affect the diagnosis in clinical practice. For example, children who are the youngest in a class are much more likely to be diagnosed as having ADHD compared to their older counterparts in the same year. This is because these children may behave more hyperactive not because they have ADHD but because they are younger and more developmentally behind. It is estimated that about 20 percent of children who are given a diagnosis of ADHD are misdiagnosed because of the month that they were born in.[98] Children who display the behavioural symptoms of ADHD but who do not have any significant functional impairments compared to their age matched peers cannot be diagnosed as having the psychiatric disorder, ADHD.[99] The previously used term ADD expired with the most recent revision of the DSM. As a consequence, ADHD is the current nomenclature used to describe the disorder as one distinct disorder that can manifest itself as being a primary deficit resulting in hyperactivity/impulsivity (ADHD, predominantely hyperactive-impulsive type) or inattention (ADHD, predominantely inattentive type) or both (ADHD combined type).[24] Classification ADHD may be seen as one or more continuous traits found normally throughout the general population. [14] It is a developmental disorder in which certain traits such as impulse control lag in development. Using magnetic resonance imaging of the prefrontal cortex, this developmental lag has been estimated to range from 3 to 5 years.[100] However, the definition of ADHD is based on behaviour and it does not imply a neurological disease.[14] ADHD is classified as a disruptive behavior disorder along with oppositional defiant disorder, conduct disorder and antisocial personality disorder.[101] The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) classifies ADHD according to the predominance of symptoms of: 1. Inattention; 2. Hyperactivityimpulsivity; 3. or a combination of both (Combined type).[24] This subdivision is based on presence of at least six out of nine long-term maladaptive symptoms (lasting at least 6 months) of either inattention, hyperactivityimpulsivity, or both. Thus, a child who is diagnosed with the inattention subtype may also show signs of hyperactivityimpulsivity, and vice-versa. To be considered, the symptoms must have appeared before the age of 6, manifest in more than one environment (e.g. at home and at school or work), and not be better explained by another mental disorder.[24] Most children with ADHD have the combined type. Children with the inattention subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but without paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice symptoms of ADHD.[24] DSM-IV As with many other psychiatric and medical disorders, the formal diagnosis is made by a qualified professional in the field based on a set number of criteria. In the USA these criteria are laid down by the American Psychiatric Association in their Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), 4th edition. Based on the DSM-IV criteria listed below, three types of ADHD are classified:[99] 1. ADHD, Combined Type is a combination of the two other ADHD subtypes.[99] 2. ADHD Predominantly Inattentive Type presents with symptoms including being easily distracted, forgetful, daydreaming, disorganisation, poor concentration, and difficulty completing tasks.[99] 13

3. ADHD, Predominantly Hyperactive-Impulsive Type presents with excessive fidgetiness and restlessness, hyperactivity, difficulty waiting and remaining seated, immature behaviour; destructive behaviors may also be present.[99] For a diagnosis of ADHD to be made the signs must not be due to the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The signs are not better accounted for by another mental disorder (such as Mood Disorder, Anxiety Disorder, Dissociative Identity Disorder, or a Personality Disorder).[24] ICD-10 In the tenth edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) the signs of ADHD are given the name "hyperkinetic disorders". When aconduct disorder (as defined by ICD-10[31]) is present, the condition is referred to as "hperkinetic conduct disorder". Otherwise the disorder is classified as "disturbance of activity and attention", "other hyperkinetic disorders" or "hyperkinetic disorders, unspecified". The latter is sometimes referred to as, "hyperkinetic syndrome".[31] Other guidelines The American Academy of Pediatrics Clinical Practice Guideline for children with ADHD emphasizes that a reliable diagnosis is dependent upon the fulfillment of three criteria:[102]

The use of explicit criteria for the diagnosis using the DSM-IV-TR. The importance of obtaining information about the childs signs in more than one setting. The search for coexisting conditions that may make the diagnosis more difficult or complicate treatment planning.

All three criteria are determined using the patient's history given by the parents, teachers and/or the patient. Adults often continue to be impaired by ADHD. Adults with ADHD are diagnosed under the same criteria, including the stipulation that their signs must have been present prior to the age of seven. Questioning parents or guardians as to how the person behaved and developed as a child also forms part of the clinical assessment of the individual; a family history of ADHD also adds weight to a diagnosis of adult ADHD due the strong heritability of ADHD.[103] While the core symptoms of ADHD are similar in children and adults they often present differently in adults than in children, for example excessive physical activity seen in children may present as feelings of restlessness and constant mental activity in adults.[103] The American Academy of Child Adolescent Psychiatry (AACAP) considers it necessary that the following be present before attaching the label of ADHD to a child:[104]

The behaviors must appear before age 7. They must continue for at least six months. The symptoms must also create a real handicap in at least two of the following areas of the childs life:

in the classroom, on the playground, at home, in the community, or in social settings.

If a child seems too active on the playground but not elsewhere, the problem might not be ADHD. It might also not be ADHD if the behaviors occur in the classroom but nowhere else. A child who shows some symptoms would not be diagnosed with ADHD if his or her schoolwork or friendships are not impaired by the behaviors.[104] Differential 14

To make the diagnosis of ADHD, a number of other possible medical and psychological conditions must be excluded. Medical conditions that must be excluded as causing the ADHD symptoms include: hypothyroidism, anemia, lead poisoning, chronic illness, hearing or vision impairment, substance abuse,medication side-effects, sleep disorders and child abuse,[105] and cluttering (tachyphemia) among others. As with other psychological and neurological issues, the relationship between ADHD and sleep is complex. In addition to clinical observations, there is substantial empirical evidence from a neuroanatomic standpoint to suggest that there is considerable overlap in the central nervous system centers that regulate sleep and those that regulate attention/arousal.[106] Primary sleep disorders play a role in the clinical presentation of symptoms of inattention and behavioral dysregulation. There are multilevel and bidirectional relationships among sleep, neurobehavioral functioning and the clinical syndrome of ADHD.[107] Behavioral manifestations of sleepiness in children range from the classic ones (yawning, rubbing eyes), to externalizing behaviors (impulsivity, hyperactivity, aggressiveness), to mood lability and inattentiveness.[106][108][109] Many sleep disorders are important causes of symptoms that may overlap with the cardinal symptoms of ADHD; children with ADHD should be regularly and systematically assessed for sleep problems.[106][110] From a clinical standpoint, mechanisms that account for the phenomenon of excessive daytime sleepiness include:

Chronic sleep deprivation, that is insufficient sleep for physiologic sleep needs, Fragmented or disrupted sleep, caused by, for example, obstructive sleep apnea (OSA) or periodic limb movement disorder (PLMD),

Primary clinical disorders of excessive daytime sleepiness, such as narcolepsy and Circadian rhythm disorders, such as delayed sleep phase syndrome (DSPS). A study in the Netherlands compared two groups of unmedicated 6-12-year-olds, all of them with "rigorously diagnosed ADHD". 87 of them had problems getting to sleep, 33 had no sleep problems. The larger group had a significantly later dim light melatonin onset (DLMO) than did the children with no sleep problems.[111]

Management Main article: Attention deficit hyperactivity disorder management Methods of treatment often involve some combination of Positive behavior support (PBS), life-style changes, counseling, and medication. A 2005 study found that medical management and behavioral treatment is the most effective ADHD management strategy, followed by medication alone, and then behavioral treatment.[112] While medication has been shown to improve behavior when taken over the short term, they have not been shown to alter long-term outcomes.[113] Medications have at least some effect in about 80% of people.[114] Dietary modifications may also be of benefit.[115] Psychosocial The evidence is strong for the effectiveness of behavioral treatments in ADHD.[116] It is recommended first line in those who have mild symptoms and in preschool-aged children.[117] Psychological therapies used include psychoeducational input, behavior therapy, cognitive behavioral therapy (CBT), interpersonal psychotherapy (IPT), family therapy, school-based interventions, social skills training, parent management training,[14] neurofeedback,[118] and nature exposure.[119][120] Parent training and education have been found to have shortterm benefits.[121] There is a deficiency of good research on the effectiveness of family therapy for ADHD, but the evidence that exists shows that it is comparable in effectiveness to treatment as usual in the community and is superior to medication placebo.[122] Several ADHD specific support groups exist as informational sources and to help families cope with challenges associated with dealing with ADHD. 15

Medication

methylphenidate (Ritalin) 10 mg tablets Stimulant medications are the medical treatment of choice.[123][124] There are a number of non-stimulant medications, such as atomoxetine, that may be used as alternatives.[123] There are no good studies of comparative effectiveness between various medications, and there is a lack of evidence on their effects on academic performance and social behaviors.[125] While stimulants and atomoxetine are generally safe, there are side-effects and contraindications to their use.[123] Medications are not recommended for preschool children, as their long-term effects in such young people are unknown.[14][126] There is very little data on the long-term benefits or adverse effects of stimulants for ADHD.[127] Any drug used for ADHD may haveadverse drug reactions such as psychosis and mania,[128] though methylphenidate-induced psychosis is uncommon. Regular monitoring of individuals receiving long-term stimulant therapy for possible treatment emergent psychosis has been recommended.[129] Tolerance to the therapeutic effects of stimulants can occur,[90] and abrupt withdrawal is not recommended.[130] People with ADHD have an increased risk of substance abuse, and stimulant medications reduce this risk.[131][132] Stimulant medications in and of themselves however have the potential for abuse and dependence.[133] Guidelineson when to use medications vary internationally, with the UK's National Institute of Clinical Excellence, for example, recommending use only in severe cases, while most United States guidelines recommend medications in nearly all cases.[134] Deficiency in zinc is more commonly found in ADHD children compared to other children. There is evidence that zinc supplementation can benefit ADHD children who have low zinc levels. [135] Prognosis Children diagnosed with ADHD have significant difficulties in adolescence, regardless of treatment.[136][137] In the United States, 37 percent of those with ADHD do not get a high school diploma even though many of them will receive special education services.[138] A 1995 briefing citing a 1994 book review says the combined outcomes of the expulsion and dropout rates indicate that almost half of all ADHD students never finish high school.[139] Also in the US, less than 5 percent of individuals with ADHD get a college degree[140] compared to 28 percent of the general population.[141] The proportion of children meeting the diagnostic criteria for ADHD drops by about 50 percent over three years after the diagnosis. This occurs regardless of the treatments used and also occurs in untreated children with ADHD.[105][142][143] ADHD persists into adulthood in about 30 to 50 percent of cases.[7] Those affected are likely to develop coping mechanisms as they mature, thus compensating for their previous ADHD.[8] Epidemiology

ADHD's global prevalence is estimated at 3 to 5 percent in people under the age of 19. There is, however, both geographical and local variability among studies. Children in North America appear to have a higher rate of ADHD than children in Africa and the Middle East.[145] Published studies have found rates of ADHD as low as 2 percent and as high as 14 percent among school-aged children.[146] The rates of diagnosis and treatment of ADHD are also much higher on the east cast of the United States than on its west coast.[147] The frequency of the diagnosis differs between male children (10%) and female children (4%) in the United States.[148] This difference between genders may reflect either a difference in susceptibility or that females with ADHD are less likely to be diagnosed than males.[149] Rates of ADHD diagnosis and treatment have increased in both the UK and the US since the 1970s. In the UK an estimated 0.5 per 1,000 children had ADHD in the 1970s, while 3 per 1,000 received ADHD medications in the late

16

1990s. In the US in the 1970s 12 per 1,000 children had the diagnosis, while in the late 1990s 34 per 1,000 had the diagnosis and the numbers continue to increase.[14] In the UK in 2003 a prevalence of 3.6 percent is reported in male children and less than 1 percent is reported in female children.[14]:134 History Hyperactivity has long been part of the human condition. Sir Alexander Crichton describes "mental restlessness" in his book An inquiry into the nature and origin of mental derangement written in 1798.[150][151] The terminology used to describe the symptoms of ADHD has gone through many changes over history including: "minimal brain damage", "minimal brain dysfunction" (or disorder),[152] "learning/behavioral disabilities" and "hyperactivity". In the DSM-II (1968) it was the "Hyperkinetic Reaction of Childhood". In the DSM-III "ADD (Attention-Deficit Disorder) with or without hyperactivity" was introduced. In 1987 this was changed to ADHD in the DSM-III-R and subsequent editions.[153] The use of stimulants to treat ADHD was first described in 1937.[154] Society and culture A number of notable individuals have given controversial opinions on ADHD. Scientologist Tom Cruise's interview with Matt Lauer was widely watched by the public in 2005. In this interview he spoke about postpartum depression and also referred to Ritalin and Adderall as being "street drugs" rather than as ADHD medication.[155] In England Baroness Susan Greenfield, a leading neuroscientist, spoke out publicly in 2007 in the House of Lords about the need for a wide-ranging inquiry into the dramatic increase in the diagnosis of ADHD in the UK and possible causes following a BBC Panorama programme that highlighted US research (The Multimodal Treatment Study of Children with ADHD by the University of Buffalo) suggesting drugs are no better than other forms of therapy for ADHD in the long term.[156] However, in 2010 theBBC Trust criticized the 2007 BBC Panorama programme for summarizing the US research as showing "no demonstrable improvement in children's behaviour after staying on ADHD medication for three years" when in actuality "the study found that medication did offer a significant improvement over time" although the long-term benefits of medication were found to be "no better than children who were treated with behaviour therapy."[157] As of 2009, eight percent of all Major League Baseball players have been diagnosed with ADHD, making the disorder common among this population. The increase coincided with the League's 2006 ban on stimulants (q.v. Major League Baseball drug policy).[158] Legal status of medications Stimulants legal status was recently reviewed by several international organizations:

Internationally, methylphenidate is a Schedule II drug under the Convention on Psychotropic Substances.[159] In the United States, methylphenidate and amphetamines are classified as Schedule II controlled substances, the designation used for substances that have a recognized medical value but present a high likelihood for abuse because of their addictive potential.[160]

In the United Kingdom, methylphenidate is a controlled 'Class B' substance, and possession without prescription is illegal, with a sentence up to 14 years and/or an unlimited fine.[161]

In Australia, stimulants such as methylphenidate and dexamphetamine are Schedule 8 controlled poisons, and as a result have strict prescribing rules due to their potential for abuse.[162]

Controversies Main article: Attention-deficit hyperactivity disorder controversies

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ADHD and its diagnosis and treatment have been considered controversial since the 1970s.[15][16][163] The controversies have involved clinicians, teachers, policymakers, parents and the media. Opinions regarding ADHD range from not believing it exists at all[164] to believing there are genetic and physiological bases for the condition as well as disagreement about the use of stimulant medications in treatment.[16][17][164] Some sociologists consider ADHD to be a "classic example of the medicalization of deviant behavior, defining a previously nonmedical problem as a medical one".[15] Most healthcare providers in U.S. accept that ADHD is a genuine disorder with debate in centering mainly around how it is diagnosed and treated.[18][19][20] The British Psychological Society said in a 1997 report that physicians and psychiatrists should not follow the American example of applying medical labels to such a wide variety of attention-related disorders: "The idea that children who dont attend or who dont sit still in school have a mental disorder is not entertained by most British clinicians." [165][166] In 2009, the British Psychological Society, in collaboration with the Royal College of Psychiatrists, released a set of guidelines for the diagnosis and treatment of ADHD.[167] In its guideline, it states that available evidence indicate that ADHD is a valid diagnosis and that medication should be the first-line treatment for adults, for children with severe ADHD, or for children with mild ADHD who do not respond to non-medication interventions. However, it states that the diagnosis lack any biological basis and that "[c]ontroversial issues surround changing thresholds applied to the definition of illness as new knowledge and treatments are developed and the extent to which it is acknowledged that clinical thresholds are socially and culturally influenced and determine how an individual's level of functioning within the 'normal cultural environment' is assessed". It further states that "the acceptable thresholds for impairment are partly driven by the contemporary societal view of what is an acceptable level of deviation from the norm." Others have included that it may stem from a misunderstanding of the diagnostic criteria and how they are utilized by clinicians,[168]teachers, policymakers, parents and the media.[164] Debates center around key controversial issues; whether ADHD is a disability or merely a neurological description, the cause of the disorder, the changing of the diagnostic criteria, the rapid increase in diagnosis of ADHD, and the use of stimulants to treat the disorder.[169] Possible long-term side-effects of stimulants and their usefulness are largely unknown because of a lack of long-term studies.[170] Some research raises questions about the long-term effectiveness and side-effects of medications used to treat ADHD.[171] In 1998, the US National Institutes of Health (NIH) released a consensus statement on the diagnosis and treatment of ADHD. The statement, while recognizing that stimulant treatment is controversial, supports the validity of the ADHD diagnosis and the efficacy of stimulant treatment. It found controversy only in the lack of sufficient data on long-term use of medications, and in the need for more research in many areas.[172] With a "wide variation in diagnosis across states, races, and ethnicities"[173] some investigators suspect that factors other than neurological conditions play a role when the diagnosis of ADHD is made.[173][174] Two studies published in 2010 suggest that the diagnosis is more likely to be made in the younger children within a grade; the authors propose that such a misdiagnosis of ADHD within a grade may be due to different states of maturity and may lead to potentially inappropriate treatment.[173][174] A further study involving a million children in British Columbia (Canada) published in 2012 using data from 1997 to 2008 unambiguously confirmed the phenomenon, finding children born in December (the youngest) 39% more likely to be diagnosed with ADHD than those born in January (the oldest).[175] In adults Main article: Adult attention deficit hyperactivity disorder Between 2 and 5 percent of adults have ADHD.[176] Between one-third,[177] and up to 80 percent of the children diagnosed with ADHD continue having symptoms well into adulthood.[178] Many adults, however, remain untreated.[179] Untreated adults with ADHD often have chaotic lifestyles, may appear to be disorganized and may rely on non-prescribed drugs and alcohol to get by.[180]They often have such associated psychiatric comorbidities as depression, anxiety disorder, substance abuse, or a learning disability.[180] Recognized as occurring in adults in 1978, it is currently not addressed separately from 18

ADHD in childhood. Obstacles that clinicians face when assessing adults who may have ADHD include developmentally inappropriate diagnostic criteria, age-related changes, comorbidities and the possibility that high intelligence or situational factors can mask ADHD.

Pengertian dan Dinamika Gangguan ADHD (1) 1. Pengertian

ADHD adalah kepanjangan dari Attention Deficit Hiperactivity Disorder. Sedangkan ADD adalah kepanjangan dari Attention Deficit Disorder. Menurut Maslim (2001: 136) hiperaktif merupakan kegelisahan yang relative berlebihan, khususnya situasi yang menuntut ketenangan. Batasan hiperaktifitas adalah tingkah laku berlebihan dalam konteks yang diharapkan pada saat itu dibandingkan dengan anak yang sama usia dan IQnya. Menurut Widodo, definisi ADHD adalah suatu peningkatan aktifitas motorik hingga pada tingkatan tertentu yang menyebabkan gangguan perilaku yang terjadi, setidaknya pada dua tempat dan suasana yang berbeda. Aktifitas anak yang tidak lazim dan cenderung berlebihan yang ditandai dengan gangguan perasaan gelisah, selalu menggerak-gerakkan jarijari tangan, kaki, pensil, tidak dapat duduk dengan tenang dan selalu meninggalkan tempat duduknya meskipun pada saat dimana dia seharusnya duduk degan tenang.. Terminologi lain yang dipakai mencakup beberapa kelainan perilaku meliputi perasaan yang meletup-letup, aktifitas yang berlebihan, suka membuat keributan, membangkang dan destruktif yang menetap. 2. 1. 1. a. Proses Perkembangan ADHD Dinamika Gangguan

Untuk memahami jalannya perkembangan ADHD, maka teori mengemukakan bahwa anak ADHD memiliki kekurangan motivasi, arousal (dorongan), self-regulasi dan penahanan respon (Respon Inhibition). Adapun penjelasannya sebagai berikut: a) Motivation Deficit : Anak ADHD menunjukan gangguan pada kesensitifan mereka terhadapreward dan punishment, b) Arousal Deficit: Anak ADHD pada umumnya memiliki dorongan yang sangat rendah, c) Self-regulation: Adanya kerusakan pada otak sehingga mereka impulsive dan memiliki kekuatan usaha yang buruk,

d) Behavior Inhibition: Anak ADHD mengalami kesulitan ketika harus mempertahankan responnya terhadap sesuatu. Hal ini berpengaruh pada kemampuan kognitif, bahasa dan motorik. Dinamika gangguan ini dapat diawali dari pengaruh genetik. Ibu yang mengkonsumsi alkohol semasa hamilnya atau mengalami komplikasi kehamilan, akan menyebabkan kerusakan pada dopamin dan kerusakan pada lobus frontalis dan ganglia basalis. Seluruh kerusakan tersebut memicu gagalnya menekan respon yang tidak tepat, sehingga kemampuan kognitif (seperti memori, self-directed dan self-regulation menjadi berkurang. Jika kemampuan kognitif mengalami kemunduran, maka anak akan mengalami inattention (sulit memusatkan perhatian pada sesuatu), hiperaktif (susah diam) dan impulsif (mengambil suatu tingkah laku tanpa dipikirkan terlebih dahulu). Perkembangan social anak yang seharusnya berjalan normal menjadi terhambat, karena biasanya anak yang mengalami hiperaktif, tidak mampu memperhatikan dan impulsive dijauhi oleh peergroupnya. Karena tuntutan tersebut, maka orang tua anak membentuk suatu pola pengasuhan yang bias saja kurang tepat untuk menangani gangguan tersebut. Pada akhirnya, anak akan mengalami gangguan tingkah laku (Mash, 2005: 129). 1. b. Komorbid ADHD

Terkadang gangguan ADHD ini tidak hanya menyerang sendiri, terdapat beberapa gangguan lain yang mungkin/biasanya muncul bersamaan dengan ADHD. Untuk mengetahui komorbid ADHD ini, maka kita harus mengetahui karakteristik umum dari ADHD ini, diantaranya adalah: a) Kurangnnya kemampuan kognitif yang berisikan empat fungsi eksekutif (proses control pada otak yang dapat

mengaktifkan, mengintegerasikan dan mengatur fungsi otak lain), meliputi: 19

i. ii. iii. motorik, iv. b) c) d) e)

Proses kognitif: berkaitan dengan memori, berpikir fleksibel, menggunakan strategi,planning dan antisipasi, Proses bahasa: meliputi kelancaran berbahasa, komunikasi dan menggunakan self-directed speech, Proses motorik: melakukan usaha, mengikuti instruksi, mempertahankan respond an mengkoordinasikan

Proses emosional: self-regulation untuk dorongan tingkah laku, mentoleransi frustasi dan alasan moral. Kurangnya intelektual: Biasanya anak ADHD memiliki IQ yang rendah, Kerusakan fungsi akademik: Anak ADHD mengalami kesulitan sekolah, Gangguan belajar: Anak ADHD sulit memfokuskan diri pada penjelasan guru sehingga sulit menyelesaikan tugas, Self persepsi yang terganggu (Mash, 2005: 118).

Setelah mengetahui karakteristik yang berhubungan dengan ADHD, maka komorbid pun dapat diketahui. Dalam buku Wenar (2005: 185-186) menjelaskan komorbid ini diantaranya adalah: a) ADHD/Distruptive Behavior

Destuptive behavior ini meliputi ODD (Oppositional Defiant Dsorder) dan CD (Conduct Disorder). Presentasinya mencapai 30-50% subjek. Terdapat sedikit perbedaan antara ADHD dan gangguan tingkah laku ini. ADHD lebih pada perilaku tidak mengerjakan tugas, kelemahan kognitif, prestasi rendah, prognosis jangka panjang baik. Sedangkan gangguan tingkah laku, dimanapun anak berada, dia lebih agresif, mungkin memiliki orang tua yang antisosial, rumah tangga penuh kekerasan, sosioekonomi rendah dan berpotensi melakukan delinkuensi dan penggunaan narkoba (Davidson, 2006: 679). b) ADHD/Gangguan Kecemasan

Sekira 10-40% anak ADHD mengalami gangguan kecemasan. Kecemasan berpotensial menimbulkan gejala gangguan tingkah laku. c) ADHD/Gangguan Mood

Sekitar 20-30% anak ADHD mengalami pengalaman depresi, sehingga memungkinkan anak tersebut mengalami perubahan mood yang drastic. d) ADHD/Gangguan Belajar

Sekitar 19-26% anak ADHD mengalami kesulitan dalam menyelesaikan tugas-tugas akademik karena mereka sulit untuk memusatkan perhatian.

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